Faculty Opinions recommendation of Risks of recurrent stroke and all serious vascular events after spontaneous intracerebral haemorrhage: pooled analyses of two population-based studies.

Introduction Blood pressure (BP) lowering reduces the risk of recurrent stroke after intracerebral haemorrhage (ICH). However, implementation of BP lowering in clinical practice in the UK is unknown. Patients and methods We identified adults with first-ever incident ICH to quantify the proportion who survived >14 days after hospital discharge and were prescribed BP-lowering medication in a prospective, population-based, inception cohort study in the Lothian region of Scotland during June 2010–May 2012 and January–December 2019. After the first cohort, we analysed reasons for avoiding BP-lowering medication in a sample from the Lothian region of the Scottish Stroke Care Audit during January 2017–November 2017, which informed a quality improvement intervention that was implemented in the second cohort. Results After efforts to improve monitoring and lowering of BP amongst ICH survivors, there was an increase in the proportion of patients prescribed BP-lowering medication at hospital discharge between the first and second population-based cohorts (81/130 [62%] vs. 68/89 [76%]; P = 0.028). Compared with patients not prescribed BP-lowering medication at hospital discharge, patients prescribed BP-lowering medication presented with higher systolic BP (177 vs. 156 mm Hg, P = 0.002 and 180 vs. 149 mm Hg, P < 0.001, in the first and second population-based cohorts, respectively), and were more likely to have pre-morbid hypertension (85% vs. 33%, P < 0.001 and 72% vs. 29%, P < 0.001) and atrial fibrillation (35% vs. 4%, P < 0.001 and 26% vs. 5%, P < 0.034). Conclusion In this population-based study, the proportion of patients with ICH who were prescribed BP-lowering medication at hospital discharge increased after a quality improvement intervention.

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Diffusion-weighted imaging lesions and risk of recurrent stroke after intracerebral haemorrhage

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2021-326116 ◽

2021 ◽

pp. jnnp-2021-326116

Author(s):

Kim Wiegertjes ◽

Lynn Dinsmore ◽

Jonathan Drever ◽

Aidan Hutchison ◽

Jacqueline Stephen ◽

...

Keyword(s):

Ischaemic Stroke ◽

Antiplatelet Therapy ◽

Intracerebral Haemorrhage ◽

Diffusion Weighted Imaging ◽

Recurrent Stroke ◽

Brain Mri ◽

Randomised Trial ◽

Cox Proportional Hazards ◽

Vascular Events ◽

Diffusion Weighted

ObjectiveTo determine whether the presence of diffusion-weighted imaging-positive (DWI+) lesions is associated with recurrent stroke after intracerebral haemorrhage (ICH).MethodsThe REstart or STop Antithrombotics Randomised Trial (RESTART) assessed the effect of restarting versus avoiding antiplatelet therapy after ICH on major vascular events for up to 5 years. We rated DWI sequences of MRI done before randomisation for DWI+ lesion presence, masked to outcome and antiplatelet use. Cox proportional hazards regression models were used to quantify associations.ResultsOf 537 participants in RESTART, 247 (median (IQR) age 75.7 (69.6–81.1) years; 170 men (68.8%); 120 started vs 127 avoided antiplatelet therapy) had DWI sequences on brain MRI at a median of 57 days (IQR 19–103) after ICH, of whom 73 (30%) had one or more DWI+ lesion. During a median follow-up of 2 years (1–3), 18 participants had recurrent ICH and 21 had ischaemic stroke. DWI+ lesion presence was associated with all stroke, (adjusted HR 2.2 (95% CI 1.1 to 4.2)) and recurrent ICH (4.8 (95% CI 1.8 to 13.2)), but not ischaemic stroke (0.9 (95% CI 0.3 to 2.5)). DWI+ lesion presence (0.5 (95% CI 0.2 to 1.3)) vs absence (0.6 (95% CI 0.3 to 1.5), pinteraction=0.66) did not modify the effect of antiplatelet therapy on a composite outcome of recurrent stroke.ConclusionsDWI+ lesion presence in ICH survivors is associated with recurrent ICH, but not with ischaemic stroke. We found no evidence of modification of effects of antiplatelet therapy on recurrent stroke after ICH by DWI+ lesion presence. These findings provide a new perspective on the significance of DWI+ lesions, which may be markers of microvascular mechanisms associated with recurrent ICH.Trial registration numberISRCTN71907627.

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Ten-year risks of recurrent stroke, disability, dementia and cost in relation to site of primary intracerebral haemorrhage: population-based study

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2019-322663 ◽

2020 ◽

Vol 91 (6) ◽

pp. 580-585 ◽

Cited By ~ 1

Author(s):

Linxin Li ◽

Ramon Luengo-Fernandez ◽

Susanna M Zuurbier ◽

Nicola C Beddows ◽

Philippa Lavallee ◽

...

Keyword(s):

Quality Of Life ◽

Intracerebral Haemorrhage ◽

Recurrent Stroke ◽

Population Based ◽

Population Based Study ◽

Effective Prevention ◽

Stroke Disability

BackgroundPatients with primary intracerebral haemorrhage (ICH) are at increased long-term risks of recurrent stroke and other comorbidities. However, available estimates come predominantly from hospital-based studies with relatively short follow-up. Moreover, there are also uncertainties about the influence of ICH location on risks of recurrent stroke, disability, dementia and quality of life.MethodsIn a population-based study (Oxford Vascular Study/2002–2018) of patients with a first ICH with follow-up to 10 years, we determined the long-term risks of recurrent stroke, disability, quality of life, dementia and hospital care costs stratified by haematoma location.ResultsOf 255 cases with primary ICH (mean/SD age 75.5/13.1), 109 (42.7%) had lobar ICH, 144 (56.5%) non-lobar ICH and 2 (0.8%) had uncertain location. Annual rates of recurrent ICH were higher after lobar versus non-lobar ICH (lobar=4.0%, 2.7–7.2 vs 1.1%, 0.3–2.8; p=0.02). Moreover, cumulative rate of dementia was also higher for lobar versus non-lobar ICH (n/% lobar=20/36.4% vs 16/20.8%, p=0.047), and there was a higher proportion of disability at 5 years in survivors (15/60.0% vs 9/31.0%, p=0.03). The 10-year quality-adjusted life years (QALYs) were also lower after lobar versus non-lobar ICH (2.9 vs 3.8 for non-lobar, p=0.04). Overall, the mean 10-year censor-adjusted costs were £19 292, with over 80% of costs due to inpatient hospital admission costs, which did not vary by haematoma location (p=0.90).ConclusionCompared with non-lobar ICH, the substantially higher 10-year risks of recurrent stroke, dementia and lower QALYs after lobar ICH highlight the need for more effective prevention for this patient group.

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